Sripal Bangalore, M Haisum Maqsood, Robert S Zhang, Sunil V Rao, Ahmed Elmorsy Mohamed, Evald H Christiansen, Lene D Andreasen, Mustafa Abomohsen, Akiko Maehara, Mamas A Mamas, Yousif Ahmad, Ulf Landmesser, Doosup Shin, Ziad Ali, Deepak L Bhatt, Gregg W Stone
In this updated meta-analysis of RCTs, after accounting for modifier effects from recent studies, ICI-guided PCI was associated with significantly reduced cardiovascular events compared with angiography-guided PCI. Geographic heterogeneity across trials was present mainly for target vessel revascularization, explained in large part by differences in lesion characteristics and procedural technique.
BACKGROUND: Recent societal guidelines provide a Class I recommendation for intracoronary imaging (ICI)-guided percutaneous coronary intervention (PCI) for complex or left main coronary artery disease; however, recent trials have failed to show a benefit.
OBJECTIVES: The study aim was to re-evaluate the efficacy of ICI-guided PCI and to explore heterogeneity of results across trials.
METHODS: PubMed, Embase, Cochrane Central, and ClinicalTrials.gov databases were searched through June 3, 2026, for randomized controlled trials (RCTs) comparing outcomes with ICI-guided PCI vs angiography-guided PCI in the drug-eluting stent era. Direct comparison meta-analyses, mixed treatment comparison meta-analyses, trial sequential analyses, fragility analysis, and Bayesian meta-analyses were performed. Meta-regression analysis was performed to evaluate heterogeneity using the following variables: stent length (surrogate for lesion length), stent diameter, difference in postdilatation (percentage) between the groups, publication year, and geographic location.
RESULTS: A total of 28 RCTs met the inclusion criteria, comprising 24,634 patients (mean age 64.8 years; 75.9% male) with a mean follow-up of 22 months. ICI-guided PCI reduced target lesion failure (relative risk [RR]: 0.72; 95% CI: 0.61-0.85; I2 = 61%), cardiac mortality (RR: 0.73; 0.58-0.91; I2 = 5%), myocardial infarction (RR: 0.86; 0.75-0.97; I2 = 0%), target vessel revascularization (RR: 0.69; 95% CI: 0.57-0.83, I2 = 41%), stent thrombosis (RR: 0.55; 95% CI: 0.40-0.76; I2 = 0%), and all-cause mortality (RR: 0.82; 95% CI: 0.70-0.96; I2 = 0%) compared with angiography-guided PCI. Trial sequential analysis confirmed evidence for at least a 20% reduction in all outcomes with ICI-guided PCI. The fragility index was robust, ranging from 9 to 50. The posterior probability for benefit was >99% for all outcomes. Trial differences in geography and lesion characteristics explained most of the between-trial variance (residual tau = 0).
CONCLUSIONS: In this updated meta-analysis of RCTs, after accounting for modifier effects from recent studies, ICI-guided PCI was associated with significantly reduced cardiovascular events compared with angiography-guided PCI. Geographic heterogeneity across trials was present mainly for target vessel revascularization, explained in large part by differences in lesion characteristics and procedural technique.